Surely, you’ve all read the grim reports about Alzheimer’s disease. The advancing age of the US population will usher forth an Alzheimer’s epidemic in the coming decade. The emotional toll of this epidemic will be immeasurable, and the financial impact could bankrupt the Medicare system.

That dire version of the story might sell newspapers, but it doesn’t really reflect the available options to a nation with a will to fight back. The good news is: we can manage this problem. And no elusive scientific discoveries are required to do so. We merely need to implement the medical knowledge that is already in hand.

To be clear, scientific advances yielding better treatments and more accurate diagnostic approaches will greatly improve our prospects in this battle. We need to aggressively fund research and push forward on that front. However, it is important to recognize the sizeable gap between the high standard of care that is achievable based on the current state of medical knowledge, and the lagging standard of care that is routinely implemented in a primary care clinic.

Pragmatism: Closing the Gap

Closing the gap in the Alzheimer’s field could yield tremendous benefits. It will take some effort, but we can achieve such a goal through pure effort and public will. Compared to solutions based on the hope of new scientific discoveries, this has the appeal of greater certainty.

To close the clinical gap, we must address three key areas where “common practices” are significantly lagging behind “best practices”.

1)Education: We need to promote public education and awareness about the many, common medical conditions that impair memory (depression, anxiety, sleep disorders, thyroid malfunction, vitamin deficiency, medications, etc). This will reduce stigma associated with memory loss and encourage patients to be more proactive in expressing early concerns to their physicians.

2)Proven Clinical Standards: We need to help primary care physicians adopt proven standards for differentiating between signs of normal aging and subtle symptoms caused by medical conditions that impair memory. Out-dated assessments for identifying dementia are aiming too late in the process; we need to facilitate effective intervention at an earlier, subtler stage of impairment. Newer clinical assessment tools can ensure that emerging problems are addressed in a timely manner, prior to unnecessary disease progression and declining health.

3)Effective Treatment: We need to ensure that patients, physicians, and caregivers can recognize what effective treatment looks like; doing so will aid ongoing compliance with a prescribed regimen of care. Compared to treatments for other causes of memory loss, expectations for treating Alzheimer’s disease are often unrealistic. For AD, effective treatment is not a complete reversal of symptoms, but rather, a slowing of functional decline. Importantly, everyone must appreciate that proper treatment for AD involves more than just drugs; it also encompasses proper diet, regular physical exercise, and tight control of other chronic conditions.

Concrete steps in these three areas will narrow the gap between “current practices” and “best practices”. Doing so will mitigate the impact from two of the most destructive components of the Alzheimer’s disease problem: under-diagnosis and under-treatment.

Under-Diagnosis

According to the World Alzheimer’s Report 2011, published by Alzheimer’s Disease International, there may be 36 million demented people in the world and 28 million of them are undiagnosed. That is, no doctor has diagnosed the underlying cause of the dementia and prescribed treatment to resolve the problem. According to well-accepted prevalence data, a large percentage of these people are demented due to Alzheimer’s disease (AD). For all of those people, their disease is progressing unabated, their symptoms are progressing, and the ongoing costs of their care are moving irreversibly upward.

Under-Treatment

As of today, AD cannot be cured, but a timely intervention including careful management of diabetes and hypertension, a proper diet, physical activity, and poly-therapy with approved Alzheimer’s drugs, can significantly slow progression for a meaningful percentage of those 28 million people who have been neither diagnosed nor treated. Additionally, many other conditions that cause memory loss are both common and completely treatable. If no diagnostic work-up is performed, these conditions go untreated at the ongoing peril of the patient’s health, which ultimately drives the cost of care higher.

Certainly, a better-educated public, timelier diagnosis of medical conditions that impair memory, and robust treatment are all central facets of a solution to the Alzheimer’s epidemic. Each has deep economic implications underscoring the importance of addressing them. As shown by examples like the Orange County Vital Aging Program*, all of these can be achieved through pragmatic, community-based efforts to improve knowledge and raise standards of care among primary care physicians.

Overall, the looming threat of an Alzheimer’s epidemic is a real problem that may well have painful consequences. We would all like more certainty that scientific efforts will soon thwart the disease, but we cannot yet count on that with high confidence. In the meantime, a concerted effort to pragmatically implement the scientific advances from the past decade of research will significantly reduce its likely impact.

As described in this complimentary post, a pragmatic solution to the looming threat of an Alzheimer’s epidemic is more likely to bear fruit than the most progressed scientific solutions. It is clear that a better-educated public, timelier diagnosis of medical conditions that impair memory, and robust treatment are all achievable endpoints in a successful campaign against this disease. Importantly, each of these can be achieved through pragmatic, community-based efforts to improve knowledge and raise standards of care among primary care physicians.

Orange County Vital Aging Program - A Community Example

How such a pragmatic program could be implemented in any given community depends largely on the particular make-up of the organizations and healthcare providers in that community. As a point of reference, the Orange County Vital Aging Program (OCVA) in southern California is already demonstrating this concept with encouraging early results. That program provides a template for success worthy of further consideration.

The philosophy behind the OCVA is that timely discourse between an educated public and a well-trained physician community can catalyze better care and improved cognitive health on a mass scale.

The program supports a free website where local residents can gather information, view a community calendar of events and lectures, use free tools for risk identification and management, and find physicians who are trained to manage cognitive health. Local physicians can use the site to register for ongoing CME courses about managing cognitive health, download guidelines for diagnosing and managing conditions that affect cognition, and to learn about community resources that might benefit their patients with memory disorders.

Having accomplished a foundation level of public education and physician training through public lectures and CME courses in its first year, the OCVA program is seeing three community trends:

1)Patients who are aging normally, but who are worried about perceived declines in their cognition, are raising concerns to their physicians and then being objectively reassured about their good health without an expensive and unnecessary work-up.

2)Patients with Alzheimer’s disease are being detected in a timely manner and can now benefit from robust intervention while their brains are still relatively healthy.

3)Patients with other causes of cognitive impairment (depression, stroke, thyroid, sleep disorder, anxiety, etc.) are being diagnosed and treated effectively.

Conclusive evidence demonstrating that the OCVA program improves health and/or lowers costs of care will not be available until longer-term follow-up is complete. But the early data suggest that the program has engaged the community and is changing the dynamic between patients and their physicians in the primary care channel.

Overall, the looming threat of an Alzheimer’s epidemic is a real problem that may well have painful consequences. We would all like more certainty that scientific efforts will soon thwart the disease, but we cannot yet count on that with high confidence. In the meantime, a concerted effort to pragmatically implement the scientific advances from the past decade of research will significantly reduce its likely impact.